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12120024 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22067 CLEARCREEK CT CONTRACTOR:DALCON,INC. PERMIT NO: 12120024 OWNER'S NAME: WHITE JOSEPH D AND SHIRLEY J T 7578 CHESTNUT ST DATE ISSUED:12/06/2012 OWNER'S PHONE: SAN JOSE,CA 95110 PHONE NO:(408)298-1690 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class��1� p!Liiee..4 S C 0q1 U PANEL UPGRADE TO 200 AMP Contractor 1. Aclo'�. Cwt ( `,�-. Wcalm I hereby affirm that I am licensed under the provisions o Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$2000 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this APN Number:32618015.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 1$ DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYSM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses ich may accrue against said City in consequence of the granting of this it. iticut .applicant understands and will comply Issued by: Date: with all non-poi so the itino Municipal Code,Section 9.18. RE-ROOFS: Signature a "' ate. -_ All roofs shall be inspected prior to any roofing material being installed.If a roof is IM installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWN -BUILDER DECLARATION Signature of Applicant: Date: I hereby affir tha am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections1,255015.,255!33,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Y lVc.`�—'K,L\l ate: permit is issued. I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino.Municipal Code,Section Licensed Professional 9.18. Signature Date GENERAL PERMIT APPLICATION P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION ME 10300 TORRE AVENUE•CUPERTINO, CA 950143255 � ' A CUPERTINO (408)777-3228• FAX(408)777-3333• buildina(CDCUDertino.org ` `\j ❑PLUMBING ❑N ECHAMCAL ZzLizcnucAL ' y/ ❑MIISSCELLANEOUS PRO]ELT ADDREBB 22C5�o _I � `o- c ejo � C� IPN ,�trL O o C,1 S OWNERNA,M �,^ ]_A PROM REETe`q—qH. /o E-MA STADDRESS V`• -i� Cf[Y ATE'ZlP✓-�'' C/CY "{ Q I _ FAX v CONTACT NAME PHONE E-MAIL STREECADDRESS CITY,STATE,ZIP FAX ❑ oviat ❑ OWNEA-BUBDER ❑ OwNER AGENT ❑ CONTRACIDA OcomT CTOR AGcT'T ❑ ARCF7rcCr ❑ENGBTu'R ❑ DI ❑TENANT CONTRACTOR NAME LICENSENUNIBER LICENSETYPE EUS.LIC# COMPANY NAME E-MAIL - FAX STREETADDRESS CITY,STATE,ZIP PHONE ARCH17'ECUENGB;MRAJa LICENSE NUMBER I BUS.LCA COMPANY NAME' E-MAIL FAX STREET ADDRESS CRY,STATE,ZIP PHONE USE OF ❑sFD V DUPIF.X ❑ MULTI-FAMBY PROJECT Pt WILDLAND ❑ YES I PROJEMN ❑YES I IS THE BLDG AN ❑ YES BURABIG: ❑MNSERCW, URBAN Mr7lFACE AREA NO FLOOD ZONE 0 N EO33--A130M E3 No DESCAIIPITON OF WORK .l.� l ins TOTALVALUATION: z ®�� RECEIVED BY: i By my signature below,I certify to each of erty owner or authorized agent to act on the proowner's behalf. I have read this application and the information I have pro is d e Description of Work and verify it is ace tc. I agree w comply with all applicable local ordinances and state laws relating to buil g 'ze r rescntatives of Cupertino to toter the about-idenLf'�edprope-y:or inspection puloses. Signature of Applicano'AgenD Date: '�/ /1�' SUPP N REQUIRED OFFICE USE ONLY O OVER-THE-COUNTER F ❑ EXPRESS u G ❑ STANDARD U ❑ LARGE ❑ NIAJOR MEPMueApp_2011.doc revised 06121111 - CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 22067 clearcreek ct DATE: 12/06/2012 REVIEWED BY: mendez APN: BP#: *VALUATION: *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration Repair PRIMARY SFD or Duplex PENTAMATION 1 REAP2 USE: PERMIT TYPE: WORK anei upgrade to 200 amp SCOPE Xlech. Plan Check Plumb, Plan Check Elec.Plan Check 0.0 hrs $0.00 Xfech. Perwil Fee: Plumb. Permit Fee: Elect.Permit Fee: IEPERAffT Other Afech. Insp. Ober Plumb Insp. Lj Other Elec.Insp. LLO J Ins IA,Iech. lusp. Fre: Plumb. husp.Fee: Elect..Imp,Fee NOTE. This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). Thesefees are based on the prelindina informationavailable and are only an estimate Contact the Dept for addnl info. FEE ITEMS /Fee Resolution 11-053 Eff 711112) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 2007 amps Electrical Suppl. PC Fee: 0 Reg. 0 OT0.0I hrs $0.00 $45.001 IERT<200 I Services PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Fee-.0 Reg. 0 OT 0,0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: T77 $45.00 Consiruction Tax: Administrative Fee: JADAffN $42.00 0 Work Without Permit? OYes F'. No $0.00 0 Advanced Planning Fee: $0.00 Select a Non-Residential 0 $45.00 Travel Documentation Fee: I TRA VDOC Building or Structure 0A Strong Motion Fee., 1BSE1SjVffCR $0.50 Select an Administrative Item Bldg St ds Commission Fee: IBCBSC $1.00 ;�;"- $133,50t $45.001 -1- _._ . ,fWtAL $178.50 Revised: 10/01/2012 Building Department City Of Cupertino 10300 Torre Avenue Cnnarhnn. M URIA_ W Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/SUBCONTRACTOR LIST JOB ADDRESS: ZaP< PERMIT# OWNER'S NAME: r wN ire PHONE# GENERAL CONTRACTORi Clryyl C BUSINESS LICENSE# ADDRESS: —, _!3qvimjjfZ;e C'14 vim ' *Our municipal code requires'allbbdsinesses working in the city to have a City of Cupertino usiness license. NO BUILDING FINAL OR FINAL ,OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR,AND ALL SUBC OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 11 11 if I am not using any subcontractors: n Date Please check applicablesp -bcontractors an plete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing 49 ,7VZL Electrical Excavation Fencing Flooring/Carpeting Linoleum/Wood Glass/Glazing_` Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile 1 1A`/17 D to Own for Signature